Summary of "Anesthesia Risk Alert Program: A Proactive Safety Initiative"

Summary published January 3, 2024

Summary by Aalok Agarwala, MD

The Joint Commission Journal on Quality and Patient Safety | June 2023

Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert Program: A Proactive Safety Initiative. Jt Comm J Qual Patient Saf. 2023 Sep;49(9):441-449. doi: 10.1016/j.jcjq.2023.06.005. Epub 2023 Jun 10. PMID: 37429758.


  • This article describes protocol implementation and early results for a screening and risk mitigation program at a nationwide anesthesia practice with 6000 clinicians practicing at nearly 450 facilities in the United States
  • Dubbed the Anesthesia Risk Alert (ARA) program, the protocol was developed following analysis of adverse event data over a 3-year period which resulted in prioritization of 5 clinical scenarios identified as being high-risk:
    • Known or suspecteddifficult airways in patients undergoing general endotracheal anesthesia (GETA)
    • Highbody mass index (BMI) (≥ 45) for patients undergoing GA
    • Patients withpulmonary hypertension
    • Patients with ASA physical status classification of 4 or 5
    • Patients at high risk for OR fire
  • Each high-risk clinical scenario was paired with a recommended risk-mitigation strategy
    • Difficult Airway – second practitioner present for induction and emergence
    • High BMI – Second practitioner present for induction and emergence
    • Pulmonary HTN – Discussion with a second practitioner
    • ASA 4 or 5 – Discussion with a second practitioner
    • High risk for OR fire – Follow institutional/APSF/ASA risk mitigation strategies
  • With extensive education and training, compliance with the protocol and action plan reached >95% over 3 years
  • Adverse events in patients with BMI >45 receiving GA decreased by 30.7% and adverse events in ASA 4 and 5 patients decreased by 67.6%. Difficult airway and pulmonary hypertension harm reduction could not be captured due to lack of data infrastructure. There was no statistically significant change in OR fires.
  • Though limited by potential underreporting of adverse events and overreporting of compliance due to self-reporting, a simple set of interventions for high-risk clinical scenarios appears to have had significant benefit in reducing critical adverse events.